A management system for diabetes in general practice

Practice patterns of rural family physicians based on the American Diabetes Association standards of care

The purpose of this study was to examine practice patterns of rural family physicians in the care of non-insulin-dependent diabetes mellitus based on the standards of care of the American Diabetes Association (ADA). One hundred patient charts were randomly chosen, twenty for each physician, from the practices of five family physicians in rural Ohio. A standardized collection protocol was used, based upon the ADA recommendations. The charts were reviewed for compliance with the ADA parameters. The patients' records demonstrated 66% compliance with dietary counseling and 33% with counseling about exercise. Moreover, there was low compliance with physical examination guidelines. Specifically, 66% of the patients had fundoscopic examination and 64% had a complete foot examination done. With respect to the laboratory guidelines, 70% of the charts reviewed had a urinalysis ordered and 45% annual lipids measured. However, glycosylated hemoglobin was performed in only 15% of the patients. The results suggest that rural family physicians do not consistently follow the ADA standards of care.

Epidemiology of known diabetes in Lombardy, north Italy. Clinical characteristics and methodological aspects

Diabetes epidemiology can benefit in Italy from the large network of outpatient diabetic clinics and patients' facilities. A large investigation was carried out in 1988, in a certain area of northern Italy, to estimate the prevalence of known diabetes. Using four information sources, 4547 distinct patients were identified. Through the capture-recapture method we assessed completeness and estimated a prevalence of 3.3%. Prevalence of type 1 diabetes was 0.8 per 1000. Italian age-standardised overall prevalence and developed-world standardised rates were 2.8% and 2.6%, respectively. A representative sample of 2358 patients was characterised through a standard questionnaire. Women were diagnosed about 6 years later than men (58.8 +/- 0.4 vs 52.9 +/- 0.4, P < 0.0001), while the duration of the disease was very similar in both sexes (9.9 +/- 0.2 vs 9.5 +/- 0.2). As regards diabetes therapy, 17.2% of the patients were on diet alone, 62.1% on oral agents and 20.6% on insulin. Among the insulin-treated subjects more than half were on adjuvant therapy with tablets, and only 6.2% were treated with 3 injections/day. Less than half of all the known diabetic subjects had had an ophthalmoscopic examination in the previous 2 years.

The role of general practitioners in diabetic eye care in Lanarkshire

This study reports data from 50 practices (3550 patients) in Lanarkshire taking part in an audit of diabetes care. Data were obtained by review of general practitioner records and the correspondence from consultants and opticians contained in them. The principal study measures examine the process of care. Overall levels of performance were low: only 35.5% of patients had visual acuity and 54.5% fundoscopy recorded in the previous year. Significantly better results were observed for both examinations in those few practices which performed these examinations in more than 10% of their patients (51.4% vs 32.0% (mean difference 19.4, 95% CI 16.1-23.7) for visual acuity and 65.7% vs 53.3% (mean difference 12.4, 95% CI 3.0-21.8) for fundoscopy. Less than half of diabetic patients in Lanarkshire currently receive adequate screening for the ocular complications of diabetes. Most practices rely on hospital diabetic and ophthalmology services. Where practices undertake ocular examination of patients, this is currently in addition to those services provided elsewhere.

Should practice nurses be involved in diabetic care?

Primary care teams who involve practice nurses in the management of patients with diabetes mellitus provide better care. Measures of the structure and process of care are improved when nurses are involved in diabetic care.

Who joins the BDA?

A comparison of demographic and clinical characteristics was made between a random sample of members and non-members of the British Diabetic Association (BDA) of working age (17-65 years) who responded to a questionnaire concerning their employment. There were large regional variations in BDA membership, but overall 27% of responders were BDA members. Of the responders, BDA members were more likely to be women than men (30 vs 25%, p = 0.04) and under rather than over the age of 36 years (38 vs 21%, p less than 0.001). A greater proportion of insulin-treated patients with diabetes were BDA members compared with patients who were not treated with insulin (37 vs 13%, p less than 0.001). Unemployment was significantly less amongst BDA members compared with non-members (12 vs 20%, p less than 0.001). Membership decreased with decreasing social status, with significantly more house-owners being BDA members compared with those living in rented accommodation (31 vs 23%, p less than 0.001).

Employers' attitudes to diabetes

In order to examine the knowledge and attitude of employers to diabetes and diabetic employees, a questionnaire was sent to a random sample of approximately 2500 businesses and industries in eight different areas of the United Kingdom. Information was collected on the employment of people with diabetes, such as sickness absence, suitability of types of job for the diabetic person, the proportion of people with diabetes registered as disabled, and the provision of pension schemes. Only 1% of firms claimed that they would not consider a person with diabetes for employment within the firm. Nearly a third of employers did not know whether they employed anyone with diabetes. Over a quarter of the manufacturing industries reported some jobs that were unsuitable and 8% reported certain unfavourable job conditions for a diabetic employee such as shift work, working at heights, strenuous work, etc. A total of 7% of those firms with a diabetic employee reported that diabetic workers were more often absent from work due to sickness and 16% of firms employing a diabetic person did not allow paid time off for clinic visits. The attitude of the majority of employers seemed to indicate that diabetes in itself does not limit employment prospects since most people with diabetes have few problems arising from their condition and can make good employees in a range of occupations.

The cost of diabetes

This paper estimates the cost of diabetes in England and Wales in 1984 to be in excess of 259.5 million pounds. The costing methodology used follows the 'cost of illness' framework. This framework defines three elements for costing: direct, indirect and psychological, although the latter element is left out of the calculation because monetary valuations for this element have never been adequately estimated. Direct costs include resources used to prevent, detect, and treat diabetes. Indirect costs relate to the loss of productive output caused by absenteeism, early retirement, and premature mortality. The estimate which has been obtained is likely to be an underestimate because of the weaknesses and gaps in the data sets. The estimate of the total lost earnings from diabetes varied greatly according to the choice of absentee rate. If there was no significant difference between absenteeism in the diabetic community and the non-diabetic community then the cost of diabetes would be 259.5 million pounds. If on the other hand the diabetic community was prone to three times as much absenteeism as the non-diabetic community then the cost of diabetes would rise to 602.5 million pounds. The costs of diabetes as a subsidiary diagnosis are extremely difficult to identify. They have been estimated in this study to be 86 million pounds but this is thought to be an overestimate. Nevertheless the cost of diabetes is significant and thus the search for more efficient treatment regimens may reduce such costs as well as enhance the quality of life of the patients concerned.(ABSTRACT TRUNCATED AT 250 WORDS)